Inequalities in total mortality and by cause of death according to the level of education in Navarra: findings from a longitudinal study from 2001 to 2008

Fundamentos: Dada la ausencia de evidencia científica, el objetivo fue mostrar las desigualdades en mortalidad según el nivel de estudios en Navarra y la contribución de las principales causas de defunción a la magnitud de desigualdades en la mortalidad por todas las causas de muerte. Métodos: Todos los ciudadanos de 25 años y mayores residentes en Navarra en 2001 fueron seguidos durante 7 años para conocer su estado vital. El indicador de posición socioeconómica utilizado fue el nivel de estudios. Se estimaron las tasas de mortalidad general y por causa de muerte ajustadas por edad según la educación. Posteriormente, se calcularon la diferencia relativa (razón) y la diferencia absoluta de tasas entre las categorías más baja y más alta de nivel de estudios y la contribución de las principales causas de muerte a la diferencia absoluta. Resultados: La razón de tasas por todas las causas de muerte fue 1,37 en hombres y 1,23 en mujeres. El virus de la inmunodeficiencia humana (VIH) (25,84) y los accidentes no intencionales (3,78) presentaron las razones de tasas más altas en los hombres y la diabetes mellitus (4,92) y el VIH (4,38) en las mujeres. Las enfermedades cardiovasculares constituyeron la causa de muerte que más contribuyó a la diferencia absoluta en mortalidad: 26% en hombres y 48% en mujeres. Conclusiones: La tasa de mortalidad en la población navarra muestra un gradiente inverso con el nivel educativo, a excepción de algunas localizaciones de cáncer. Las enfermedades cardiovasculares son la causa de muerte que más contribuye a las desigualdades absolutas en mortalidad, mientras que otras causas de muerte que muestran importantes desigualdades relativas contribuyen poco a las desigualdades absolutas.Background: Due to the lack of evidence, the objective was to show the inequalities in mortality by educational level in Navarra and the contribution of the main causes of death to the magnitude of inequalities in mortality from all causes of death. Methods: All citizens aged 25 years and older residing in Spain in 2001 were followed during 7 years to determine their vital status. Level of education was used as socioeconomic status indicator. It was estimated the age-adjusted total mortality rate and mortality rate from cause-specific mortality by educational level. Then it was calculated the relative difference (ratio) and the absolute difference in rates between the lowest and highest levels of education and the contribution of the main causes of death to the absolute difference. Results: The rate ratio for all causes of death was 1.37 in men and 1.23 in women. The human immunodeficiency virus (HIV) (25.84) and unintentional injuries (3.78) are the causes of death with higher rate ratio in men and diabetes (4.92) and HIV (4.38) in women. Cardiovascular diseases were the leading causes of death that contribute most to the absolute difference in mortality: 26% in men and 48% women. Conclusions: The mortality rate in the Navarre population shows an inverse gradient with educational level, except in some cancer sites. Cardiovascular disease is the leading cause of death that contributes most to the absolute inequalities in mortality, while other causes of death that show significant relative inequalities, contribute little to the absolute inequalities.Fundación Caja Navarr

Patrones geográficos de la mortalidad y de las desigualdades socioeconómicas en mortalidad en España

Fundamentos: Las estimaciones sobre desigualdades socioeconómicas en mortalidad a partir de registros individuales de defunciones y población son escasas y proceden únicamente de la la ciudad de Barcelona, la Comunidad de Madrid y el País Vasco. El objetivo del presente estudio fue mostrar el patrón geográfico de mortalidad en diferentes grupos socioeconómicos, así como el de las desigualdades en mortalidad en el conjunto del territorio español. Métodos: Se realizó el seguimiento de todos los individuos mayores de 25 años del censo de población 2001 durante siete años y dos meses para conocer su estado vital (196.470.401 personas-año a riesgo y 2.379.558 defunciones). Se calculó la tasa de mortalidad ajustada por edad en hombres y mujeres por provincia y nivel de estudios. Las desigualdades en mortalidad provinciales se estimaron mediante la razón de tasas de mortalidad en los sujetos con nivel de estudios primarios o inferiores respecto a los sujetos con estudios universitarios. Resultados: En mujeres, las razones de tasas más bajas –entre 1,06 y 1,16- se observaron Palencia, Segovia, Guadalajara y Ávila. Las más altas –entre 1,53 y 1,75- en Málaga, Las Palmas, Ceuta, Toledo y Melilla. En hombres, las razones de tasas más bajas –entre 1,00 y 1,12- se observan en Guadalajara, Teruel, Cuenca, La Rioja y Ávila y las más altas –entre 1,47 y 1,73- en Las Palmas, Cantabria, Murcia, Melilla y Ceuta. Conclusiones: El patrón geográfico de las tasas de mortalidad en España varía según el nivel educativo. Las desigualdades en mortalidad muestran menor magnitud en las provincias del centro peninsular.Background: Estimates of socioeconomic inequalities in mortality coming from individual data sources were only available from Madrid, the Basque Country and the city of Barcelona. The aim of this study was to show the geographical pattern of mortality in different socio-economic groups, as well as that of inequalities in mortality in the whole Spanish territory. Methods: All people aged 25 and older in the 2001 census were followed for seven years and two months to determine their vital status (196 470 401 person-years at risk and 2,379,558 deaths). The socioeconomic variable was educational level. Age-adjusted mortality rate was estimated for women and men in every province and in each category of educational level. Inequalities in mortality in each province have been estimated by the ratio of mortality in subjects with primary or lower level of education compared to subjects with university education. Results: In women, the lowest rate ratios –between 1.06 and 1.16- are observed in Palencia, Segovia, Guadalajara, Avila and Castellon and the highest -between 1.53 and 1,75- in Malaga, Las Palmas, Ceuta, Melilla and Toledo. In men, the lowest rate ratios -between 1.00 and 1.12 – are observed in Guadalajara, Teruel, Cuenca, La Rioja and Ávila and the highest -between 1.47 and 1,73- in Las Palmas, Cantabria, Murcia, Melilla and Ceuta. Conclusions: The geographical pattern of mortality rates in Spain varies by educational level. Inequalities in mortality by education have the lowest magnitude in central peninsular provinces

The association of geographic coordinates with mortality in people with lower and higher education and with mortality inequalities in Spain

Objective. Geographic patterns in total mortality and in mortality by cause of death are widely known to exist in many countries. However, the geographic pattern of inequalities in mortality within these countries is unknown. This study shows mathematically and graphically the geographic pattern of mortality inequalities by education in Spain. Methods. Data are from a nation-wide prospective study covering all persons living in Spain's 50 provinces in 2001. Individuals were classified in a cohort of subjects with low education and in another cohort of subjects with high education. Age- and sex-adjusted mortality rate from all causes and from leading causes of death in each cohort and mortality rate ratios in the low versus high education cohort were estimated by geographic coordinates and province. Results. Latitude but not longitude was related to mortality. In subjects with low education, latitude had a U-shaped relation to mortality. In those with high education, mortality from all causes, and from cardiovascular, respiratory and digestive diseases decreased with increasing latitude, whereas cancer mortality increased. The mortality-rate ratio for all-cause death was 1.27 in the southern latitudes, 1.14 in the intermediate latitudes, and 1.20 in the northern latitudes. The mortality rate ratios for the leading causes of death were also higher in the lower and upper latitudes than in the intermediate latitudes. The geographic pattern of the mortality rate ratios is similar to that of the mortality rate in the low-education cohort: the highest magnitude is observed in the southern provinces, intermediate magnitudes in the provinces of the north and those of the Mediterranean east coast, and the lowest magnitude in the central provinces and those in the south of the Western Pyrenees. Conclusion. Mortality inequalities by education in Spain are higher in the south and north of the country and lower in the large region making up the central plateau. This geographic pattern is similar to that observed in mortality in the low-education cohort.This study was funded by UCM-Banco de Santander (GR3/14)

Clinical Outcomes of a Zika Virus Mother-Child Pair Cohort in Spain

BACKGROUND: Zika virus (ZIKV) infection has been associated with congenital microcephaly and other neurodevelopmental abnormalities. There is little published research on the effect of maternal ZIKV infection in a non-endemic European region. We aimed to describe the outcomes of pregnant travelers diagnosed as ZIKV-infected in Spain, and their exposed children. METHODS: This prospective observational cohort study of nine referral hospitals enrolled pregnant women (PW) who travelled to endemic areas during their pregnancy or the two previous months, or those whose sexual partners visited endemic areas in the previous 6 months. Infants of ZIKV-infected mothers were followed for about two years. RESULTS: ZIKV infection was diagnosed in 163 PW; 112 (70%) were asymptomatic and 24 (14.7%) were confirmed cases. Among 143 infants, 14 (9.8%) had adverse outcomes during follow-up; three had a congenital Zika syndrome (CZS), and 11 other potential Zika-related outcomes. The overall incidence of CZS was 2.1% (95%CI: 0.4-6.0%), but among infants born to ZIKV-confirmed mothers, this increased to 15.8% (95%CI: 3.4-39.6%). CONCLUSIONS: A nearly 10% overall risk of neurologic and hearing adverse outcomes was found in ZIKV-exposed children born to a ZIKV-infected traveler PW. Longer-term follow-up of these children is needed to assess whether there are any later-onset manifestations

Preoperative risk stratification in endometrial cancer (ENDORISK) by a Bayesian network model: A development and validation study

Background: Bayesian networks (BNs) are machine-learning-based computational models that visualize causal relationships and provide insight into the processes underlying disease progression, closely resembling clinical decision-making. Preoperative identification of patients at risk for lymph node metastasis (LNM) is challenging in endometrial cancer, and although several biomarkers are related to LNM, none of them are incorporated in clinical practice. The aim of this study was to develop and externally validate a preoperative BN to predict LNM and outcome in endometrial cancer patients.Methods and findings: Within the European Network for Individualized Treatment of Endometrial Cancer (ENI-TEC), we performed a retrospective multicenter cohort study including 763 patients, median age 65 years (interquartile range [IQR] 58-71), surgically treated for endometrial cancer between February 1995 and August 2013 at one of the 10 participating European hospitals. A BN was developed using score-based machine learning in addition to expert knowledge. Our main outcome measures were LNM and 5-year disease-specific survival (DSS). Preoperative clinical, histopathological, and molecular biomarkers were included in the network. External validation was performed using 2 prospective study cohorts: the Molecular Markers in Treatment in Endometrial Cancer (MoMaTEC) study cohort, including 446 Norwegian patients, median age 64 years (IQR 59-74), treated between May 2001 and 2010; and the PIpelle Prospective ENDOmetrial carcinoma (PIPENDO) study cohort, including 384 Dutch patients, median age 66 years (IQR 60-73), treated between September 2011 and December 2013. A BN called ENDORISK (preoperative risk stratification in endometrial cancer) was developed including the following predictors: preoperative tumor grade; immunohistochemical expression of estrogen receptor (ER), progesterone receptor (PR), p53, and L1 cell adhesion molecule (L1CAM); cancer antigen 125 serum level; thrombocyte count; imaging results on lymphadenopathy; and cervical cytology. In the MoMaTEC cohort, the area under the curve (AUC) was 0.82 (95% confidence interval [CI] 0.76-0.88) for LNM and 0.82 (95% CI 0.77-0.87) for 5-year DSS. In the PIPENDO cohort, the AUC for 5-year DSS was 0.84 (95% CI 0.78-0.90). The network was well-calibrated. In the MoMaTEC cohort, 249 patients (55.8%) were classified with Conclusions: In this study, we illustrated how BNs can be used for individualizing clinical decision-making in oncology by incorporating easily accessible and multimodal biomarkers. The network shows the complex interactions underlying the carcinogenetic process of endometrial cancer by its graphical representation. A prospective feasibility study will be needed prior to implementation in the clinic.</div

An evaluation of emergency guidelines issued by the World Health Organization in response to four infectious disease outbreaks.

BACKGROUND:The production of high-quality guidelines in response to public health emergencies poses challenges for the World Health Organization (WHO). The urgent need for guidance and the paucity of structured scientific data on emerging diseases hinder the formulation of evidence-informed recommendations using standard methods and procedures. OBJECTIVES:In the context of the response to recent public health emergencies, this project aimed to describe the information products produced by WHO and assess the quality and trustworthiness of a subset of these products classified as guidelines. METHODS:We selected four recent infectious disease emergencies: outbreaks of avian influenza A-H1N1 virus (2009) and H7N9 virus (2013), Middle East respiratory syndrome coronavirus (MERS-CoV) (2013), and Ebola virus disease (EVD) (2014 to 2016). We analyzed the development and publication processes and evaluated the quality of emergency guidelines using AGREE-II. RESULTS:We included 175 information products of which 87 were guidelines. These products demonstrated variable adherence to WHO publication requirements including the listing of external contributors, management of declarations of interest, and entry into WHO's public database of publications. For guidelines, the methods for development were incompletely reported; WHO's quality assurance process was rarely used; systematic or other evidence reviews were infrequently referenced; external peer review was not performed; and they scored poorly with AGREE II, particularly for rigour of development and editorial independence. CONCLUSIONS:Our study suggests that WHO guidelines produced in the context of a public health emergency can be improved upon, helping to assure the trustworthiness and utility of WHO information products in future emergencies

Correction: An evaluation of emergency guidelines issued by the World Health Organization in response to four infectious disease outbreaks.

[This corrects the article DOI: 10.1371/journal.pone.0198125.]

Evaluation of contact tracing activities during the Ebola virus disease outbreak in Guinea, 2015

Abstract Objectives The objective of the study was to present the findings of an audit tool aimed at assessing contact tracing activities during an Ebola outbreak. Methods The tool was based on Ebola guidelines and observations in the field. It was composed of 38 indicators covering contact tracing preparatives, resources, procedures and results. Results All contact tracing teams were assessed in Boké and Conakry prefectures (24 supervisors, 22 community workers, 442 contacts) between 1 July and 10 August 2015. Contact lists had less than a 40% accomplishment rate. 7% of the contacts were not seen by community workers or supervisors. ‘No touch policy' was fully respected. Conclusion Audit checklist helped to systematically identify critical issues related to contact tracing